ICAAP Actions on CPT Code 96110 for …

1 1 ICAAP Actions on CPT code 96110 for developmental screening The Illinois Chapter, american academy of Pediatrics ( ICAAP ) has provided comments on the November 1, 2011 final rule titled Medicare Program; Payment Policies Under the Physician Fee Schedule, Five-Year Review of Work Relative Value Units, Clinical Laboratory Fee Schedule: Signature on Requisition, and Other Revisions to Part B for CY 2012. Context Under the Affordable Care Act, the nationally recognized Bright Futures guidelines, developed in partnership by the american academy of Pediatrics and the Health Resources and Services Administration will require health plans to cover preventive care for children based on these guidelines. The Bright Futures guidelines recommend structured developmental screening routinely to both help health care professionals identify children who need referral for diagnostic assessment and families needing psychosocial referral, as well as engage families in identifying concerns.

2 National experts have found that systematically eliciting parental concern about development is an important mechanism for identifying children with developmental problems. Through the Enhancing Developmentally Oriented Primary Care (EDOPC) project (a partnership of the Advocate Health Care Healthy Steps Program and ICAAP ) and in collaboration with many partners in the early childhood community, ICAAP has worked diligently to advance standardized developmental screening for young children. We have seen developmental screening rates and access to Early Intervention services increase substantially and appropriately in Illinois, in no small part due to use and promotion of the 96110 code . Changes on the recently-released Physician Fee Schedule could damage this progress. Course of Recent Events Recently, the american Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel revised code 96110 . Prior to 2012, code 96110 was described as developmental testing; limited in their official code listing, but was more commonly understood as developmental screening .

3 code 96110 was therefore recently revised as developmental screening to more accurately reflect current practice and AAP recommendations. ICAAP and its partners agreed with this change. developmental testing involves a face-to-face objective service in which the physician directly observes the child performing tasks on a standardized test. On the other hand, developmental screening asks a child s observer to provide his/her observations of the child s skills, and these are recorded on a standardized and validated screening instrument. developmental screening is subjective and effectively appraises the patient s skills through the observation by a caregiver, whereas developmental testing actually measures what the patient is able to do on a standardized psychometric instrument. However, the redefinition of 96110 triggered other changes. With the release of the 2012 RBRVS final rule, the Centers for Medicare and Medicaid Services (CMS) changed the status indicator on code 96110 from A (Active) to X (Statutory Exclusion) and correspondingly 2 removed the previously-published RUC-recommended RVUs from inclusion on the 2012 Medicare RBRVS physician fee schedule.

4 ICAAP does not agree with this change. Implications As a result of this change, CMS may now consider this service excluded from its jurisdiction because it is a screen and Medicare has an established policy of nonpayment for screening services. However, ICAAP believes the editorial revision for CPT code 96110 from developmental testing; limited to developmental screening should not preclude payment for this specific service. Whereas the results of other screenings do not result in a specific diagnostic path, developmental screening is more specific and results in formal assessment of specific domains. Whether there is referral for more comprehensive testing or not, a developmental screening does form the foundation for identification of treatable developmental conditions. Therefore it warrants consideration for payment. Additionally, it is critically important that CMS publish the RUC-recommended values for code 96110 on the Medicare RBRVS physician fee schedule.

5 Although very few pediatric services are included in the Medicare program, payment policies introduced in Medicare are frequently adopted by state Medicaid/CHIP programs and eventually by private payers. In Illinois, the Medicaid program has adopted unbundled payment for code 96110 and developed pay-for-performance incentives to encourage developmental screening and referral to Early Intervention services. This payment has been critical in increasing access to these services, which will ultimately improve child health outcomes. Exclusion from the Medicare fee schedule could force reconsideration of this decision by both public and private payers. ICAAP Response ICAAP has submitted comments requesting that CMS change the status indicator of code 96110 back to status indicator A, indicating Active and eliminating the concern that it is not warranted for payment. ICAAP members and other stakeholders interested in commenting on the November 1, 2011 final rule titled Medicare Program; Payment Policies Under the Physician Fee Schedule, Five-Year Review of Work Relative Value Units, Clinical Laboratory Fee Schedule: Signature on Requisition, and Other Revisions to Part B for CY 2012.

6 , are encouraged to do so, by January 3, 2012. Information in this article may be used, as could the more simple language below: As a [state your professional capacity], I am writing to express my concern with CMS recent decision to change the status of CPT code 96110 , rendering the code ineligible for reimbursement under Medicare. Since Medicare payment rules often influence Medicaid and private payments, and since more than half of all Medicaid recipients are children, this decision could adversely impact children covered by Medicaid and private insurance. Please reverse this decision and reinstate coverage of services associated with code 96110 .